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“AN EVALUATION OF CT IMAGING FEATURES
WITH CLINICAL OUTCOME IN MODERATE TO
SEVERE TRAUMATIC BRAIN INJURY”
DISSERTATION SUBMITTED TO
THE TAMIL NADU Dr. M.G.R MEDICAL UNIVERSITY, CHENNAI
IN PARTIAL FULFILLMENT OF THE REGULATIONS FOR THE
AWARD OF DEGREE OF M.D IN RADIODIAGNOSIS.
BY
DR . ARUN KUMAR .V.B
GUIDE
DR .RAJAKUMAR.R
DEPARTMENT OF RADIOLOGY
PSG INSTITIUTE OF MEDICAL SCIENCES AND RESEASRCH
PEELAMEDU, COIMBATORE – 641004
TAMILNADU, INDIA
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled “An evaluation of ct
imaging features with clinical outcome in moderate to severe
traumatic brain injury” is the bonafide original work of Dr.Arun kumar
V. B .in the department of Radiodiagnosis, PSG Insatitute of Medical
Sciences and Research, Coimbatore in partial fulfillment of the regulations
for the award of degree of M.D in Radiodiagnosis.
Signature of the guide
Dr. Rajakumar .R D MRD DNB
Professor of Radiology
Department of Radiology
P.S.G IMSR,
Coimbatore
CERTIFICATE
PSG INSTITIUTE OF MEDICAL SCIENCES AND RESEASRCH
COIMBATORE
This is to certify that the Dissertation work entitled “An evaluation of ct
imaging features with clinical outcome in moderate to severe
traumatic brain injury” is the bonafied work of n Dr.Arun kumar V.B in
the department of Radiodiagnosis, PSG Institute of Medical Sciences and
Research, Coimbatore in partial fulfillment of the regulations for the
award of degree of M.D in Radiodiagnosis.
Dr. B.Devanand
Professor and HOD
Department of Radiodiadnosis
PSG IMS & R
Place : Coimbatore
Date :
Dr.S. Ramalingam
Principal
PSG IMS & R
ACKNOWLEDGEMENT
Foremost, I would like to express my sincere gratitude to my
professor and HOD Dr. B. Devanand and my guide
DR . R Rajakumar for his ever friendly co-operation which was
present throughout the preparation of this work. This work would
not have been possible without his guidance, support and
encouragement.
I would like to thank Dr.S. Ramalingam Principal of PSG
medical college for providing me with the opportunity and
resources to accomplish my research .
I would like to thank and express my sincere gratitude to
Dr. S. Raghu for helping me with the statistical analysis and proof
reading, enabling me to complete this study. My fellow
postgraduate in the department Dr. sitara and Dr. sukitra whose
help was available round the clock and helping me overcome
obstacles , big and small.
PLAGIARISM REPORT FROM TURNITIN.COM
TABLE OF CONTENTS
S. NO CONTENT PAGE
NO
1 INTRODUCTION 1
2 AIMS AND OBJECTIVES 8
3 MATERIALS AND METHODS 10
4 REVIEW OF LITERATURE 17
5 OBSERVATION AND RESULTS 41
6 DISCUSSION 59
7 SUMMARY 64
8 CONCULSION 66
9 LIMITATIONS & RECOMMENDATIONS 69
10 IMAGES 72
11 BIBLIOGRAPHY
12 ANNEXURES
13 MASTER CHART
ABSTRACT
AIM & OBJECTIVE
• To assess the imaging characteristic of primary brain injury on the
first CT scan.
• Predicting the clinical outcome based on individual
imaging features
MATERIAL AND METHODS
In our prospective cohort study, which includes 85 patients with moderate to
severe head injury(<12), with positive neuro parenchymal findings on first CT
scan of post trauma patients were included.
Individual imaging characteristic and their effect on patients mortality were
assessed by statistical methods like chi square test and multivariate logistic
regression analysis.
RESULTS
Regression analysis was used to asses mortality outcome gives significant p
value for following factors like Basal cistern effaced – 0.042, Midline shift -
0.036, intra ventricular hemorrhage – 0.017, herniation – 0.08, Diffuse axonal
injury 0.04
In our study mortality is more with a midline shift of >1omm, diffuse axonal
injury grade 3, basal cistern effacement, intra ventricular hemorrhage, brain
herniation .
CONCLUSION
Based on the study the individual multivariate parameters assessment is
helpful in predicting the mortality rate and outcome of the patients. So here by
conclude that initial CT imaging and its multivariate regression analysis can assess
the outcome of the patient.
2
INTRODUCTION
Traumatic brain injury(TBI) is an insult to the brain from an
external mechanical force leading to temporary or permanent
impairment of physical ,cognitive, and psychological functions, which
may lead to altered or diminished state of consciousness.
Traumatic brain injuries are the leading cause of morbitity,
mortality and disability.1
The CT scan of patient is useful, not only in demonstrating the
underlying neuro parenchymal injury but can also play a predictive role
in traumatic brain injury 1
TBIs are the commonest cause of morbidity, mortality, disability
and socioeconomic losses .
Commonest causes of traumatic brain injury are
• Falls,
• Motor vehicle accidents
• Assaults,
• Penetrating trauma and sports-related injuries
3
Severity of TBI is classified as mild, moderate and severe
according to the traumatic brain injury patients the level of consciousness
is measured by Glasgow coma scale (GCS). Most of the traumatic brain
injuy patients who arrive to the hospital are already intubated or
undergoes immediate intubation, ventilated and paralyzed .So accurate
estimation of the GCS score or changes in the GCS score after post
trauma in the initial hours is therefore difficult to obtain.
Due to availability, affordability and shorter scan time along with
bone fracture delineation, CT is preferred over MRI as a primary
investigation of traumatic brain injury.
Computed Tomography scanning of head is routinely done in all
severe brain injury patients which provides information for further
management including surgical intervention or intracranial pressure (ICP)
monitoring.
It may also provide prognostic significance information.
4
Neuro parenchymal brain injury CT findings that are relevant for
prognosis were
• Basal cisterns effacement,
• Traumatic SAH (t SAH),
• Presence and degree of midline shift and
• Type of intracranial injuries like epidural, subdural or intra
cerebral hematomas, the roles of these variables, were evaluated
individually and in combinations in various studies.
Predicting the diagnosis with early rapid management prevents from
the complications of traumatic brain injury.
Rapid and good treatment can drastically improve patients condition.
CT findings helps in identifying the neuroparenchymal injury and
grade the severity of the injury and operability status.
In unconscious patients complete neurological examinations cannot
be performed , So CT Imaging can be useful in surgical planning and
anatomical information for planning skin incision and burr holes
placement.
Even though MRI is more accurate and sensitive in diagnosing
neuroparenchymal pathology in traumatic brain injury patients, CT
imaging is preferred because of following factors like
5
• Shorter time duration
• Less cost
• Performed easily when patient is uncooperative/ventilator support.
So it becomes initial modality of choice for traumatic brain injury.
MDCT has drastically reduced scanning time and motion artifacts.
CT imaging plays a major role in identifying and detecting the
skull fractures , parenchymal and subarachnoid hemorrhage
Limitations of convential CT imaging are
• Beam-hardening artifacts/effects,
• Signal displacement (adjacent bones and metal objects ) ,
• Calcification ,
• Small amount of blood can be missed (volume averaging).
CT done within three hours of trauma may underestimate injury as
they lag behind actual intracranial damage.
It is under research whether to proceed repeated CT imaging in the
absence of neurological status changes when admission CT was normal.
After forty-eight to seventy two hours of injury, MRI is found
superior to CT. Even though CT identifies the bony defect and early
6
hemorrhage, MRI detection of hematoma changes with the blood
composition. MRI shows no abnormality in majority of mild traumatic
brain injury patients .
The most common abnormal CT findings include
• Cortical hemorrhagic contusions,
• Altered white matter signal intensity
• Permanent hemosiderin deposition on MRI will be seen in
resolving hematoma.
• Petechial hemorrhage
MRI is better than CT in detecting
• Diffuse axonal injury,
• Small hemorrhagic contusion,
• Subtle neuronal damage.
Sensitivity of MRI is useful in the detecting sub acute and chronic
hemorrhagic stages .
7
Sensitivity of MRI has improved with new MRI technology that includes
- FLAIR sequence
- Suppresses the high signal intensity
- It has more sensitivity in identifying traumatic brain injuries
and hematomas
• McGowan and colleagues demonstrated sensitivity to MRI can be
improved with magnetization transfer imaging where there is
radio frequency to the protons in tissues rather than water protons
.
• MRS is highly predictive tool in detecting axonal injury in
traumatic brain injury patients.
• In mild TBI patients, Functional MRI is helpful in detecting
activation of particular part of the brain .
• PET / SPECT imaging are not used routinely in acute traumatic
head injury.
Limitations are
- lack of availabity
- longer scan time
PET and SPECT imaging gives only functional information 1-6
8
AIM AND OBJECTIVE
9
OBJECTIVES
• To assess the imaging characteristic of primary brain injury on the
first CT scan.
• Predicting the clinical outcome based on individual imaging
features
10
MATERIAL AND METHODS
11
MATERIAL AND METHODS
STUDY TYPE : Prospective Cohort
STUDY PERIOD : July 2012 To Auguest 2014.
STUDY POPULATION : 85 Consecutive head injury patients with
positive neuro parenchymal findings in
CT scan with GCS less than 12.
CT SCANNER : Siemens somatom definition edge.
C2 level to vertex
Mode –spiral non contrast
Scan orientation- Caudo-cranial
Scan time : 5 to 6sec
Kvp/mA- 100 to120 kvp, 300 to 320 mAs
12
Inclusion & Exclusion Crireria
Inclusion criteria
Head injury patients with positive neuro parenchymal findings in
CT scan with GCS less than 12.
Exclusion criteria
• Poly trauma,
• GCS more than 12
13
Criteria Flow Chart
Head injury Head injury patients with positive neuroparenchymal
CT finding
with GCS less than 12
assess the imaging characteristics of brain injury
patient outcome is measured 6months after discharge
predicting the clinical outcome based on individual imaging
features.
14
Variables
Demographic variables
AGE
SEX
GCS
Independent variables
Extradural hemorrhage
Subdural hemorrhage
Subarachnoid hemorrhage
Intraventricular hemorrhage
Diffuse axonal injury
Hemorrhagic contusion
Herniation
Midline shift
Basal cistern effaced/compessed.
Dependent variable
Live
Death
Glasgow Outcome Scale (GOS)
15
Table: 1
Grade 1 - Good recovery Resumption of normal activities
even through there may be minor
neurological or psychological
deficits.
Grade 2 - Moderate disability [Disabled but independent] patient
is independent as far as daily life is
concerned. The disabilities found
include varying degrees of
dysphasia, hemi paresis, or ataxia,
as well as intellectual and memory
deficits and personality changes.
Grade 3 - Severe disability [Conscious but independent] patient
depends upon other for daily
support due to mental or physical
disability or both.
Grade 4 - Persistent vegetative state Patient exhibits no obvious cortical
function.
Grade 5 - Death
16
Statistical Methods
• Appropriate graphs and tables have been done.
• Association between categorical variables was performed using
pearsons chi square test ( fishers exact in case of 2x2 table)
Formula-( )
• Multivariate analyses were performed to see effect of CT finding
in presence of other with mortality as dependent variable.
Formula – (Y=a + b1X1 + b2X2 + b3X3)
17
REVIEW OF LITERATURE
18
REVIEW OF LITERATURE
The Glasgow Coma Scale rates the patient's level of consciousness
from 1 (worst) -- 15 (no impairment) based on patient's motor , verbal
and eye response which is used to assess severity of traumatic brain
injury7-9.
Few studies shows that imaging is not required unless the GCS
score is below 137-9
.
European Brain Injury Consortium conducted a survey in
patients with severe and moderate head injury where the GCS score was
testable only in 56% of patients at the time of admission . Prognostic
factors based on technical examinations results are therefore needed7-9.
Based on CT findings focal and diffuse traumatic brain injuries can
be classified10
.
Marshall et al. in 1991 analysed the Traumatic Coma Data Bank
and proposed CT classification for grouping the patients where the
classification identifies traumatic brain injury patients into six groups10
.
Further it was divided into four categories based on the patients
with and without mass lesions10
.
19
Maas et al in 2005 had examined the Prognostic performance of
traumatic brain injury by refinning and reevaluating the CT imaging
characteristic helpful to form classification with additional CT imaging
findings10
.
They developed a simple CT prognostic score (Rotterdam CT score)
that are better than the Marshall scheme and have more association with
clinical outcome when applied to Tirilazad Database which consists of
2249 patients10
.
Traumatic brain injuries are broadly classified as primary or
secondary & diffuse or focal.
Primary lesions are
• Skull fracture,
• Scalp hematoma,
• Laceration
• Extradural subarachnoid and subdural hemorrhage,
• Intraventricular hemorrhage,
• Diffuse axonal injury,
• Hemorrhagic contusion,
• Deep cerebral gray matter injury
20
Secondary lesions are
• Cerebral herniation ,
• Diffuse cerebral edema,
• Traumatic ischemia/infarction.
• Hypoxic injury 11
Extradural hemorrhage
Haemorrhage seen between the outer layer of dura and inner
surface of the skull vault which results from fracture lacerating the
middle meningeal artery/dural venous sinuses. It is associated with
fractures in 85% to 95% 11
EDH is usually unilateral but bilateral or multiple EDH have also
been reported.
• Supratentorial (90-95% )
o temporoparietal (60%)
o frontal ( 20%)
o parieto-occipital ( 20%)
• Infratentorially in posterior fossa (5-10%)
21
Biconvex shape which displaces the gray / white matter . out of
which two third of them are of high density and one third are mixed
density which indicates active bleeding. Most commonly located beneath
the squamous part of temporal bone.
Depending on the size, secondary features which include midline
shift and herniation will be present.In acute bleeding during CT will
show the non- clotted blood as less hyperdense with swirl sign .
An extradural haematoma is limited by the cranial sutures and will
be located with in the inner surface of the scalp between dura mater and
bone.
Fracture with displacement of the extradural haemorrhages can
cross the adjacent cranial suture.
Postcontrast extravasation will be seen in acute EDH.
Neovascularization and minimal enhancement (peripheral) will be
seen in chronic EDH .12-13
22
Subdural hemorrhage
Cresent shaped blood collection between the dural and arachnoid
meningeal layers are classified as subdural hemorrhage. Low GCS score
on admission(15
) in a patient with subdural hemorrhage. subdural
haematomas are usually unilateral ( 85 %).
Location - middle cranial fossa
- fronto-parietal convexities
- Common in cases of non-accidental trauma.
CT findings varies with time duration.
Hyper-acute
Appear isodense to brain parenchyma with swirling pattern
appearing hypo in case of active bleeding. Part adjacent to swirling part
predominantly appears hyper dense in most cases.
Acute
It is homogeneously hyper dense collection present extra axially in
the hemisphere. Density will increase if clot retracts and SDHs have
mixed hyper / hypo dense collection, which indicates blood which is not
clotted, serum after clot retraction, or CSF within the subdural collection.
23
In case of severe anemia or coagulopathies, the acute SDHs will appear
as isodense rarely.
Subacute
As clot advances and protein degradation occurs, the density
decreases. By 10 - 14 days it becomes iso-dense to the adjacent cortex
Indirect signs are
• CSF filled sulci
• Mass effect
• Cortex thickening
Chronic
Subdural hemorrhage appears hypodense but sometimes becomes
iso- dense to CSF.
Acute on chronic
Acute haemorrhage in a chronic subdural hemorrhage appears as
hypodense in CT imaging (15
).
24
Traumatic Subarachnoid Hemorrhage
Hemorrhage occurring in the subarachnoid space due to stretching
or tearing of predominantly meningeal vessels, branch of external carotid
artery . Association between severity of CT finding and presence of
SAH with worse patient outcome.(12)
The sensitivity of CT in detecting subarachnoid blood is
influenced by both the amount of blood and the time since the
haemorrhage. The diagnosis is suspected when the subarachnoid space is
filled with hyperattenuating material.
Traumatic SAH is seen around the circle of Willis or in the sylvian
fissure.
Small amounts of blood can also be seen in the interpeduncular
fossa, or within the occipital horns of the lateral ventricles 12
Diffuse Axonal Injury
Diffuse axonal injury is the commonest cause of significant
mortality resulting from axonal shearing forces in grey white matter
interface, corpus callosum, and brain stem 21
Mild diffuse axonal injury mostly not be seen in CT imaging. CT
imaging appears as less sentivitity for diffuse axonal injury.
25
Some who had normal intial CT brain can have a diffuse axonal
injury later will be detected in MRI.
The imaging features depends upon the presence of haemorrhagic
lesions. Hemorrhagic lesions will appears as hyper dense and size is
ranging from millimeters to centimeters . Non-hemorrhagic lesions will
be hypo dense. Both types will be seen at the grey-white matter junction,
in the corpus callosum and in the brainstem. . Diffuse axonal injury will
be associated cerebral edema and Significant cerebral ewelling.
CT imaging is found to be insensitive in case of non-hemorrhagic
lesions and only detects 19% non hemorrhagic lesions, where as MRI
will detect 92% of such lesion 4. In case of large hemorrhagic lesions CT
is very sensitive. It is presumed that in small hemorrhagic lesions in the
CT, there will be increased degree of damage and MRI is likely to detect
more number of such lesions.
• DAI grade I – small hemorrhagic foci will be seen in between grey
and white matter interfaces
o periventricular temporal lobes ,frontal lobes, periventricular
temporal lobes are commonest location.
o Identified in MRS
26
• DAI grade II : small hemorrhagic foci in corpus callosum with
grade I findings.
o posterior body and splenium are commonest location is
most frequently unilateral
o identified in SWI
o 20%
• DAI grade III : small hemorrhagic foci in brainstem with DAI
grade1and 2 findings.
o Rostral midbrain, superior cerebellar peduncles, medial
lemnisci and corticospinal tracts 21
.
Hemorrhagic Contusion
It is the commonest primary traumatic brain injury. Commonly
involved lobes are , frontal and para sagittal temporal
On CT appears as patchy ill defined low density lesions that may
be mixed with smaller high density foci of petechial hemorrhage.
Most contusions occurs as a result of the brain force against the
surface of the skull.
27
Cerebral contusions locations , depends on
• The skull cavity shape &
• Direction of head strike
• counter coup & coup injury anterior cranial fossa floor.
Hemorrhagic contusion will vary with shape and size with
different patients.
Hemorrhagic contusions will change according to stages no
weeks, hemorrhagic foci
In chronic stages the hemorraghic contusion will causes surrounding
edema and produce gliotic changes. 22
Intraventricular Hemorrhage
Defined as the presence of blood in the intraventricular system .On
CT appear as high density intraventricular blood . it occurs in 1-5% of
patients with traumatic head inury.(24-25
)
Non contrast CT imaging plays an important role in evaluating
onset of sudden headache and stroke.
On CT imaging, ventricles blood will appears as hyperdense
more than CSF density.
28
It is predominately visualized in occipital horns.
Significant blood will tends to fill the ventricle, and resulted in
clot formation.
The CT imaging findings will be helpful in identifying &
differentiating obstructive hydrocephalus & ex-vacuo dilatation in the
ventricles.
Consequence of severe trauma associated with diffuse axonal
injury and trauma of deep grey and brain stem.24
CEREBRAL EDEMA
Massive cerebral edema with intracranial hypertension is the most
life threatening (26)
. Diffuse cerebral edema seen in 10-20 %(27)
, on CT it
exhibits homogenously decreased attenuation with loss of grey and white
matter interface with hyperdense cerebellum.
Increased water content of brain/ increased intravascular blood
volume.
Vasogenic and cytotoxic edema coexist ( Vasogenic edema
immediately followed by cytotoxic edema) .
Evolves over 24-48hrs, generally resolves in 2 weeks.26,27
29
Brain Herniation
Commonest supra tentorial brain hernaitions occurs in TBIs are
subfalcine, central trans tentorial and uncal herniation.
Subfalcine herniation is one of the most commonest type of
herniation in TBIs.
Subfalcine herniation occurs mainly due raised intracranial
pressure which causes brain displacement. 28,29
Radiographic features
Subfalcine shift is evaluated by drawing line from falx to
posterior most part of septum pellucidum on axial CT images.
Septum pellucidum shift can be measured ( millimeter) by
evaluating distance from the level of midline
Imaging Characteristic features are
• Dilated CSF spaces on one side of cerebral hemisphere
• Anterior falx asymmetry
• Dilated lateral ventricle on side with compression lateral ventricle
on the controlateral side will be seen.
30
MRI
Coronal MRI is useful in identifying the herniation Intracranial
hemorrhage or tumour results from unilateral pathologhy can cause mass
effect and brain displacement.
Complications
Obstruction of the foramen of Monro results in contralateral
hydrocephalus) compression of ACA branches results in anterior
cerebral artery territory infarct . 28-29
In 1983 Lobato RD et al noted that in the patients with severe
traumatic brain injuries, there are large variations and characterizations
in the type of intracranial lesion and clinical duration30
.
So it becomes important to divide these patients into subgroups
for analyzing the factors which are influencing outcome30
.
Computerized tomography (CT) is useful in segregating the cases
on the basis of pathological and helful in correlate anatomical findings
with neurological changes .
31
They had observed following CT imaging patters in a series of
277patients. –
Pattern 1 – pure extracerebral haematoma
Pattern 2 – extracerebral haematoma plus acute hemispheric
swelling
Pattern 3 – single brain contusion, whether or not associated
with neighbouring extracerebral haematoma
Pattern 4 – Multiple unilateral contusion, whether or not
associated with subdural haematoma
Pattern 5 – Multiple bilateral brain contusions
Pattern 6 – General brain swelling whether or not associated
with small extracerebral haematoma
Pattern 7 – diffuse axonal injury
Pattern 8 – normal CT scans
And found that outcome with patients 1,3,6 and 8 was significantly
better than patterns 2,4,5,7 (when assed with categories introduced by
Jennett B, Bond M.( persistently vegetative state and dead, severe
disability, moderate disability Good recovery)30
In 1979, A pilot study to determine the feasibility of Traumatic
Coma Data Bank (TCDB) was undertaken. The objective of this study
32
was to gather prospective data on a large number of patients suffering
severe head injury so that specific questions regarding particular subsets
of these patients could be addressed As expected, there was an extremely
strong relationship (p<0.001) between intracranial diagnosis and
outcome27
.
However this type of pooling of data will masks diffuse injury
groups of patients. Where as these group of patients are high risk for
infarct and intracranial hypertension with higher mortality rates as
pointed out by Marshall et al. A general lack of recognition of the
importance of certain CT findings led them to develop a new
classification (TCDB CLASSIFICATION). Such classification would
allow for early prediction of outcome based on factors like age, clinical
status, CT findings are known.
The intent of this classification was two fold : 1) accurate
classification of severe head injury and gives accurate prediction imaging
diagnosis at the early time of the patient’s evaluation about the fatal /
nonfatal outcome condition. They divided the abnormalities seen in CT
in to six categories. They found that there is a striking direct relationship
between outcome and initial ct scan diagnosis. (P=0.0002) The CT
imaging diagnosis has important and sensitivity in predicting the status
of mortality (P=0.0001) When motor and age score included in the
33
model in the CT scan often appeared to be a more accurate predictor of
the ultimate course of patients27
.
In the TCDB classification,
In a study, head injury patients were subjected to CT and
following parameters including age, Glasgow score (GCS), injury
severity score (ISS), pupil score were studied, the CT scan was simply
classified according to presence of hematoma . But classification was
according to diffuse injury patients without hematoma were placed in the
same category as with patients whose scan was normal. However model
suggested that the CT was the more better predictor of clinical outcome
than clinical baseline characteristics, also suggested that presence of any
hemorrhage was predictive of a poor outcome.27
A good relationship between CT scan findings, the frequency of
elevated ICP, morbitity and motality in the population indicates that the
CT findings are strongly predictive of the likelihood of intracranial
hypertension and that there is a relationship, perhaps not completely
defined, between the degree of intracranial hypertension and the
likelihood of the dead.
Marshall’s classification 31 32
is tabulated below.
34
Marshall’s classification
Table no: 2
Karl Greene in1995 had told that subarachnoid hemorrhage was
the one of the poor prognosis then the injury separately which is
Category Definition
Diffuse injury I
(no visible pathology)
No visible intracranial pathology seen on CT
scan
Diffuse injury II Cisterns are present with midline shift 0-5mm
and /or :
Lesions densities present
No high or mixed density lesion > 25cc
May include bone fragments and foreign bodies
Diffuse injury III
(Swelling)
Cisterns compressed or absent with midline shift
0-5mm, no high or mixed density lesion > 25cc
Diffuse injury IV
(Shift)
Midline shift > 5mm, no high or mixed density
lesion > 25cc
Evacuated mass lesion Any lesion surgically evacuated
Non evacuated mass
lesion
High or mixed density lesion >25cc, not
surgically evacuated
35
obtained on first admission CT scan with penetrating and non
penetrating severe traumatic brain injury33
.
The present grading systems for traumatic brain injury had classify
patients according to finding which is obtained on the first admission
CT scan and their CT findings correlate with outcome not taken the
presence of subarachnoid hemorrhage , the amount of subarachnoid
hemorrhage and location33
.
Then they developed another new grading mentioned below for
traumatic SAH that was significantly relating to the clinical outcome at
the head injury patients discharge from the hospital with a study
population of 52 retrospective head injury patients.
Grade 1 indicated thin Tsah (Less than or Equal to 5 mm)
Grade 2, thick t SAH (greater than 5mm)
Grade 3 thin Tsah with mass lesion (s) and a shift less than or
equal to 5mm
(3A) or greater than 5mm (3B)
Grade 4, Thick Tsah with mass lesion and shift less than or equal
to 5mm.
(4A) or greater than 5mm (4B)
36
In their study they have had concluded that basal cistern
effacement was on the most significant factor in regression model,
second most to basal cistern is thickness of traumatic subarachnoid
hemorrhage at the time of discharge at Glasgow outcome scale.33
In the year 2005, ANDREW I.R.MASS ET AL from Erasmus
Medical Center, Rotterdam, Netherlands not only analysed the existent
marshall classification but also confirmed its predictive value. In
addition it was found that additional discrimination can also be obtained
by using full use of individual CT imaging characteristics particularly
with mass lesion like EDH and SDH underlying the CT classification of
marshall 10
Rotterdam computed tomographic score given below was derived
after studying a sample size of 2249.10
37
Rotterdam CT score
Table no: 3
Predictor value Score
Basal cisterns
Normal 0
Compressed 1
Absent 2
Midline shift
No shift or shift less than or equal to 5mm. 0
Shift greater than 5mm 1
Epidural mass lesion
Present 0
Absent 1
Intraventricular blood or SAH
Absent 0
Present 1
38
Rotterdam CT score
Table: 4
Score No of patients Actual mortality %
1 36 0
2 600 6.8
3 773 16
4 465 26
5 261 53
6 114 61
But patients with mild head injury were not included in this study it
was suggested that early predicting outcome in traumatic brain injury
could be significantly improved by adding more CT imaging parameter
to model and further characterization of CT imaging parameter viz,
SAH / IVH, basalcisterns, midline shift, and mass lesions like(EDH Vs
intradural lesions).
In traumatic brain injury, they suggested to use combinations of
individual CT imaging features rather than the classification of marshall
for prognostic purposes .10
39
Many studies had examined the various association between
imaging findings in CT , severity of injuries and outcome in traumatic
brain injury patients.
Other studies asseses whether the CT scan imaging findings will
help in predicting the outcome, and suggested classifying — the trauma
coma data bank (TCDB) classification, Marshall et al, etc.
Previous classifications has several problems which limits
generalisability. Classifications in patients with severe head injury
mostly are GCS<87-9
.
Particular intracranial hematoma and the mass effect shows
important impact over the decision to repeat CT scan. In times of clinical
deterioration, scan CT was repeated and will not reveal necessary of
surgical intervention. Few other studies have shown that no interventions
were performed on repeat CTs until the patient had presented with
coagulopathy, hypotension 34
.
In traumatic brain injury, many study models (93%) are from high
income countries32
.
Prognostic models which are frequently published are developed
from small samples of patients, rarely validated on external populations
and poor methodological quality. It is not useful for clinically practice
40
Only few models are from low and middle income population in
developed countries ( where trauma occurs mostly). There were only 2%
models are taken from low income countries 32
41
OBSERVATION AND RESULTS
42
OBSERVATION AND RESULTS
AGE
In this study , patients age were ranging from 16 to 70years.
Out of 85 patients, 20-40yrs age group contributes maximum of 49
patients.
TABLE NO: 5
Age No of patients
Less than 20yrs 4
20-40 yrs 49
40- 60yrs 10
>60yrs 8
43
GRAPH NO :1
AGE
< 20yrs 20-40 yrs 40-60yrs >60
4
49
108
AGE
AGE
44
SEX
Out of 85 patients, study sample consists of 71 male and 14
female
TABLE NO: 6
Male 71
Female 14
GRAPH NO :2
SEX
Male
84%
Female
16%
SEX
45
GCS
The mean GCS was 8 plus or minus 2 ranging from 1t012. A
patient was considered to have severe head injury if GCS was 8or less
which was observed in 46 patients and moderate head injury if GCS is
between 12 to 9 which was observed in 39 patients
TABLE NO: 7
Moderate head injury 39
Severe head injury 46
GRAPH NO :3
GCS
moderate
46%severe
54%
GCS
46
MAJOR CT Findings
TABLE NO: 8
CT FINDINGS NO OF PATIENTS
Extra dural hemorrhage 27
Subdural hemorrhage 60
subarachnoid hemorrhage 77
contusion 71
intraventricular hemorrhage 12
Basal cistern effaced 16
Midline shift 30
diffuse axonal injury 6
47
GRAPH NO :4
CT FINDING
27
60
7771
1216
30
6 5
CT finding
CT finding
48
Extra Dural Hemorrhage
Out of 85 patients, extra dural hemorrhage were observed in 27
patients in whom three died.
TABLE NO: 9
EDH Death Alive Total
Present 3 (11.1%) 24 (89.9%) 27
Absent 24(41.4%) 34 (58.6%) 58
GRAPH NO : 5
EXTRA DURAL HEMMORRHAGE
11.1
41.4
Present Absent
Death
Alive
49
Subdural Hemorrhage
Out of 85 patients, sub dural hemorrhage were observed in 60
patients in whom 20 died.
TABLE NO: 10
SDH Death Alive Total
Present 20 (33.7%) 40 (66.7%) 60
Absent 7 (28%) 18 (72%) 25
GRAPH NO : 6
Subdural Hemorrhage
33.3 28
Present Absent
Death
Alive
50
Subarachnoid Hemorrhage
Out of 85 patients, sub arachnoid hemorrhage were observed in
77patients in whom 26 died.
TABLE NO: 11
SAH Death Alive Total
Present 26 (33.8%) 51 (62.2%) 77
Absent 1 (12.5%) 7 (87.5%) 8
GRAPH NO : 7
Subarachnoid Hemorrhage
33.8
12.5
Present Absent
Death
Alive
51
Contusion
Out of 85 patients, Contusion were observed in 71patients in whom
22 died.
TABLE NO: 12
Contusion Death Alive Total
Present 22 (31%) 49 (69%) 71
Absent 5 (35.7%) 9(64.3%) 14
GRAPH NO : 8
Contusion
31 35.7
Present Absent
Death
Alive
52
Intraventricular Hemorrhage
Out of 85 patients, Intraventricular hemorrhage wereObserved in
12 patients in whom 9 died.
TABLE NO: 13
IVH Death Alive Total
Present 9 (75%) 3 (25%) 12
Absent 18 (24.7%) 55 (75.3%) 73
GRAPH NO : 9
Intraventricular Hemorrhage
75
24.7
Present Absent
Death
Alive
53
Basal cistern Effacement
Out of 85 patients, Basal Cistern effacement wereobserved in 16
patients in whom 8 died.
TABLE NO : 14
GRAPH NO : 10
Basal cistern effacement
50
27.5
Effaced Nil
Death
Alive
Basal cistern
effacement
Death Alive Total
Present 8 (50%) 8(50%) 16
Absent 19 (27.5%) 50 (72.5%) 69
54
Midline Shift
Out of 85 patients, midline shift were observed in 30 patients, in whom
12 died.
Table no: 15
Midline shift death alive total
1-5mm 6(35.3%) 11(64.7%) 17
5-10mm 2(25%) 6(75%) 8
>10mm 4(80%) 1(20%) 5
absent 15(27.3%) 40(72.7%) 55
GRAPH NO : 11
Midline Shift
27.335.3
25
80
Nil 1 -5mm 5 - 10mm >10mm
Death
Alive
55
Diffuse Axonal Injury
Out of 85 patients, diffuse axonal injury were observed in 6 patients in
whom 3 died.
TABLE NO: 16
DAI Death Alive Total
Grade1 - - -
Grade2 2(40%) 3(60%) 5
Grade3 1(100%) 0 1
absent 24(30.4%) 55(69.4%) 79
GRAPH NO : 12
Diffuse Axonal Injury
30.440
100
Nil Grade 2 Grade 3
Death
Alive
56
Herniation
Out of 85 patients, herniation were observed in 5 patients in
whom 4 died.
TABLE NO : 17
Herniation Death Alive Total
Present 4(80%) 1 (20%) 5
Absent 23 (28.8%) 57 (71.2%) 80
GRAPH NO : 13
Herniation
80
28.8
Present Absent
Death
Alive
57
Total no of Patients (Glascow Outcome Scale)
Out of 85 traumatic brain injury patients (GCS less than 12 )
TABLE NO: 18
Glascow Outcome Scale No of patients
Grade1 48
Grade2 7
Grade3 3
Grade4 8
Grade5 19
Total 85
58
GRAPH NO : 14
Total no of Patients (Glascow Outcome Scale)
0
5
10
15
20
25
30
35
40
45
50
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Total no of Patients
Total no of Patients
59
DISCUSSION
60
DISCUSSION
India has 1% of the worlds vehicles, but 6% of total global RTA
deaths . Economic loss amounts to Rs 550 crores ( most of the RTAs
effect the brain).
Assessment of prognosis of traumatic brain is one of the neglected
areas in research barring a few attempts to create scoring system.
First CT scan of traumatic brain injury patient is used not only in
diagnosing neuroparenchymal injury but also plays predictive role.
Various classification system like one given by marshall et al 1991
to the recent Rotterdam scoring system 2005 have been applied to assess
prognosis of the patients.
Study was compared with Marshall and Rotterdam CT scoring
systems, individual findings of CT which in included in these analysis
system to predict the early mortality of patient having traumatic brain
injury.
The marshall et al traumatic coma data bank classification includes.
Diffuse injury - 1,
Diffuse injury - 2,
61
Diffuse injury - 3,
Diffuse injury - 4,
Evacuated mass lesion - 5,
Non evacuated mass lesion - 6
The Marshall scoring mainly depends on the basal cistern
involvement, middle line shift, evacuation and non evacuation mass
lesion.
According to the Marshall et al CT finding and type of
hemorrhagic mass management, patients with involvement of high or
mixed density lesion with in brain >25cc volume not surgically removed
has bad prognosis and high mortality score is near to 6
( P value < 0.0001).
Rotterdam (2005) CT scoring system includes
Traumatic subarachnoid hemorrhage along with basal cistern
effacement, midline shift, EDH, intraventricular hemorrhage.
Based on the Rotterdam scoring the score of 6 has mortality 61%
having basal cistern effacement, midline shift present >5mm, epidural
hematoma , Intra ventricular hemorrhage , adding all of this with 1.
P value of <0.0001 in a score 6 has a high mortality rate.
62
As compared to Marshall et al and Rotterdam scoring in our study
individual parameters in CT findings show significant P value suggesting
high mortality in following parameters like basal cistern effacement,
midline shift, diffuse axonal injury .
In our prospective cohort study, which includes 85 patients with
moderate to severe head injury(GCS<12), various CT parameters
(observed on first CT scan post trauma) were studied for their effect on
patients mortality.
The results were analysed .
Association between categorical variables was performed using
pearsons chi square test ( fishers exact in case of 2x2 tables).
Multivariate analyses were performed to see the effects of a CT
finding in presence of other with mortality as the dependent variable.
It chi square test tells about the relationship between outcome of
the patient and each variable. Chi square formula -( )
Associated variables are
Midline shift
Basal cistern
Intra ventricular hemorrhage
63
Herniation
Diffuse axonal injury
Hence, multivariate regression analysis results showed that above
mentioned variables are closely associated with outcome of the patients
who encountered head injury. Formula – (Y=a + b1X1 + b2X2 + b3X3)
CT findings that were statistically significantly indicative of
mortality in multivariate scenario were
Basal cistern effaced – 0.042
Midline shift - 0.036
Intraventricular hemorrhage – 0.017
Herniation – 0.08
Diffuse axonal injury – 0.04
The primary advantage of predicting percentage mortality is
especially important in country like ours, where there are limited
financial resources.
This will help the patients family to have a better insight about the
patient condition and the likely outcome.
64
SUMMARY
65
SUMMARY
• In our prospective cohort study, which includes 85 patients with
moderate to severe head injury(<12), with positive neuro
parenchymal findings on first CT scan of post trauma patients
were included.
• Individual imaging characteristic and their effect on patients
mortality were assessed by statistical methods like chi square test
and multivariate logestic regression analysis.
• we concluded that following CT imaging findings like
o Intraventricular hemorrhage
o basal cistern effacement
o midline shift more than 10mm
o grade 3diffuse axonal injury
o brain herniation
were noted to affect patients mortality adversely .
66
CONCLUSION
67
CONCLUSION
In our study, following factors on baseline CT scan were noted to affect
patients mortality adversely.
1) 75% of patients with mortality had intraventricular hemorrhage .
2) 50% of patients with mortality had basal cisterns effaced.
3) 80% of patients with mortality had midline shift more than 10mm.
25 – 35% patients with mortality had midline shift below 10mm.
4) Prognosis of diffuse axonal injury worsens with its grades, highest
with grade 3 seen in 100% of patients with mortality.
5) 80% of patients with mortality had herniation
6) In our study less than 15% of patients with mortality had subdural
hematoma and 33% of patients with mortality had subarachnoid
hemorrhage.
7) Regression analysis was used to asses mortality outcome gives
significant p value for following factors like
o intraventricular hemorrhage
o basal cistern effacement
o diffuse axonal injury
o herniation
o midline shift
68
8) The predicted percentage of mortality gives a better insight about
better condition outcome to patients family where it can help them
for financial aspect and it also help their family to decide on the
expensive therapeutic option.
69
LIMITATIONS AND RECOMMENDATION
70
LIMITATIONS
• In our study, we are not able to accomplish large population group
due to loss of patients follow up and inadequate volume of
cases(moderate to severe traumatic brain injury).
• Combination of individual imaging features not assessed.
• We have not included the mild head injury patients who can also
have less chance of mortality
71
RECOMMENDATIONS
We recomment combination of individual CT imaging features in a large
group with wide characterization of individual imaging features.
72
IMAGES
73
Figure 1 : EXTRADURAL HEMORRHAGE
75
Figure 3 : SUBARCHNOID HEMORRHAGE
76
Figure 4 : HEMORRHAGIC CONTUSION
77
Figure 5 : DIFFUSE AXONAL INJURY
78
Figure 6 : INTRAVENTRICULAR HEMORRHAGE
79
Figure 7 : Subfalcine HERNIATION
80
Figure 8 : Uncal herniation
81
Figure 9 : MIDLINE SHIFT
83
Grade 5
Figure 11(a) : Intraventricular Figure 11(b) : Hemorrhage in
haemorrhage corpus callosum
.
84
Figure 12 (a) subarachnoid Figure 12 (b) subdural
hemorrhage hemorrhage
85
Figure 13 : Hemorrhagic contusion
86
Grade 5
Figure 14(a) subdural hemorrhage Figure 14(b) hemorrhagic
contusion
87
Figure 15 subfalcine herniation
88
Figure 16(a) Midline shift Figure 16 (b) basal cistern effacement
89
Figure 17. Subarchnoid hemorrhage
90
DAI grade 3
Figure 18(a) haemorrhagic foci Figure 18(b)intraventricular
Haemorrhage in brain stem
91
Figure 19(a) subdural hemorrhage Figure 19(b) hemorrhagic contusion
92
Grade3
Figure 20(a) hemorrhagic contusion Figure 20(b) subdural
hemorrhage
93
Figure 21(a) Subarachnoid Figure 21(b) Hemorrhagic
hemorrhage contusion
94
Figure 22 hemorrhagic cistern
95
Grade2
Figure 23(a) subfalcine herniation Figure 23(b) Extradural
hemorrhage
96
Figure 24(a) Hemorrhagic contusion Figure 24(b) Midline shift
97
Figure 25 Subarchnoid hemorrhage
98
Figure 26(a) Subdural hemorrhage Figure26 (b) Hemorrhagic contusion
99
Figure 27(a) Extradural hemorrhage Figure27(b) subarachnoid
hemorrhage
100
Figure 28 Midline shift
101
64 year old male with grade 1 outcome
Figure 29(a)Extradural hemorrhage Figure29 (b) subdural hemorrhage
102
Figure 30(a) subarachnoid hemorrhage Figure30(b) Hemorrhagic
contusion
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ANNEXURES
ANNEXURES
FIGURE 1 : EXTRADURAL HEMORRHAGE
FIGURE 2 : SUBDURAL HEMORRHAGE
FIGURE 3 : SUBARCHNOID HEMORRHAGE
FIGURE 4 : HEMORRHAGIC CONTUSION
FIGURE 5 : DIFFUSE AXONAL INJURY
FIGURE 6 : INTRAVENTRICULAR HEMORRHAGE
FIGURE 7 : SUBFALCINE HERNIATION
FIGURE 8 : UNCAL HERNIATION
FIGURE 9 : MIDLINE SHIFT
FIGURE 10 : BASAL CISTERN EFFACEMENT
FIGURE 11(A) : INTRAVENTRICULAR
FIGURE 11(B) : HEMORRHAGE IN
HAEMORRHAGE CORPUS CALLOSUM
FIGURE 12 (A) : SUBARACHNOID
FIGURE 12 (B) : SUBDURAL HEMORRHAGE
HEMORRHAGE
FIGURE 13 : HEMORRHAGIC CONTUSION
FIGURE 14(A) : SUBDURAL HEMORRHAGE
FIGURE 14(B) : HEMORRHAGIC CONTUSION
FIGURE 15 : SUBFALCINE HERNIATION
FIGURE 16(A) : MIDLINE SHIFT
FIGURE 16 (B) : BASAL CISTERN EFFACEMENT
FIGURE 17 : SUBARCHNOID HEMORRHAGE
FIGURE 18(A) : HAEMORRHAGIC FOCI IN BRAIN STEM
FIGURE 18(B) : INTRAVENTRICULAR HAEMORRHAGE
FIGURE 19(A) : SUBDURAL HEMORRHAGE
FIGURE 19(B) : HEMORRHAGIC CONTUSION
FIGURE 20(A) : HEMORRHAGIC CONTUSION
FIGURE 20(B) : SUBDURAL HEMORRHAGE
FIGURE 21(A) : SUBARACHNOID HEMORRHAGE
FIGURE 21(B) : HEMORRHAGIC CONTUSION
FIGURE 22 : HEMORRHAGIC CISTERN
FIGURE 23(A) : SUBFALCINE HERNIATION
FIGURE 23(B) : EXTRADURAL HEMORRHAGE
FIGURE 24(A) : HEMORRHAGIC CONTUSION
FIGURE 24(B) : MIDLINE SHIFT
FIGURE 25 : SUBARCHNOID HEMORRHAGE
FIGURE 26(A) : SUBDURAL HEMORRHAGE
FIGURE26 (B) : HEMORRHAGIC CONTUSION
FIGURE 27(A) : EXTRADURAL HEMORRHAGE
FIGURE27(B) : SUBARACHNOID HEMORRHAGE
FIGURE 28 : MIDLINE SHIFT
FIGURE 29(A) : EXTRADURAL HEMORRHAGE
FIGURE29 (B) : SUBDURAL HEMORRHAGE
FIGURE 30(A) : SUBARACHNOID HEMORRHAGE
FIGURE30(B) : HEMORRHAGIC CONTUSION
TABLES
TABLE 1 : GLASGOW OUTCOME SCALE (GOS
TABLE 2 : MARSHALL S CLASSIFICATION
TABLE 3 : ROTTERDAM CT SCORE
TABLE 4 : ROTTERDAM PROGNOSTIC SCORE
TABLE 5 : AGE
TABLE 6 : SEX
TABLE 7 : GCS
TABLE 8 : MAJOR CT FINDINGS
TABLE 9 : EXTRADURAL HEMORRHAGE & MORTALITY
TABLE 10 : SUBDURAL HEMORRHAGE
TABLE11 : SUBARACHNOID HAEMORRHAGE
TABLE12 : CONTUSION
TABLE13 : INTRAVENTRICULAR HEMORRHAGE
TABLE14 : BASAL CISTERN EFFACEMENT
TABLE15 : MIDLINE SHIFT
TABLE16 : DIFFUSE AXONAL INJURY
TABLE17 : HERNIATION
TABLE18 : TOTAL NO OF PATIENTS (GLASCOW
OUTCOME SCALE)
GRAPH
GRAPH 1 : AGE
GRAPH 2 : SEX
GRAPH 3 : GCS
GRAPH 4 : MAJOR CT FINDINGS
GRAPH 5 : EXTRADURAL HEMORRHAGE & MORTALITY
GRAPH 6 : SUBDURAL HEMORRHAGE
GRAPH 7 : SUBARACHNOID HAEMORRHAGE
GRAPH 8 : CONTUSION
GRAPH 9 : INTRAVENTRICULAR HEMORRHAGE
GRAPH 10 : BASAL CISTERN EFFACEMENT
GRAPH 11 : MIDLINE SHIFT
GRAPH 12 : DIFFUSE AXONAL INJURY
GRAPH 13 : HERNIATION
GRAPH 14 : TOTAL NO OF PATIENTS (GLASCOW
OUTCOME SCALE)
MASTER CHART
S.
NO NAME ID NO AGE GCS EDH SDH
SA
H
CONT
USION IVH
BASAL
CISTERN MIDLINE SHIFT DAI HERINIATION surgery NO DAYS IN HOSPITAL
OUT
COME
comp effacd 1-5
mm
5-
10 >10 SF V C TC TA TO
1-
5days 5-10days >10days
1 subash I13023785 19/M 9 x x x 14 days * grade 1
2 nazeema I13038105 44/F 9 x x x x x x 13days * grade 1
3 Kuppayamal.v I14002179 55/M 6 x x X x x x x grade 5
4 Bakyam I14001789 38/F 12 X x 7 days * grade1
5 Rajendran I12007197 46/M 10 X x 1days * * grade 1
6 karuppasamy I13024418 45/M 4 X x x x 7 days * grade 1
7 murugesan I13029666 31/M 12 x X x x 14 days * grade 1
8 elangovan I13024418 49/M 12 X x X 30days * grade 1
9 Devaramal I14001419 55/F 8 X x x x x x 14days * grade 1
10 unnikrishnan I13004409 65/M 9 x x x x 27days * grade 5
11 gopal I13017843 45M 10 x x x x 18 days * grade 5
12 dhanalakshmi I13016362 61/F 3 x x x x x 3days * grade 5
13 Dilipkumar I13012245 24/M 11 x x x x 12 days * grade 1
14 sivaraj I14002008 40/M 10 x x X x 12days * grade1
15 Robert stalin I13017167 26/M 2 x x x x s 38days * grade 1
16 Duraisamy I14018355 61/M 5 x x x 1day * grade 5
17 MANIAN I12008681 34/M 6 x x 13days * grade 2
18 venugopal I12007075 23/M 11 x 15days * grade 1
19 gowtham raj I12004192 18/M 6 x x 26 days * grade1
20 Boopathy I13003175 35/M 12 x x x x 11 days * grade 1
21 Selvaraj M I13013303 29/M 12 x x x x 18 days * grade 1
22 tamilvanan I13013277 19/M 4 x x x x g3 60 days * grade 4
23 arasan I13025385 65/M 10 x x x x 30days * grade 1
24 nagaraj I12025427 36/M 11 x x x S 150 days * grade 2
25 ramolini I12025562 22/F 4 x x x x s 90 days * grade 1
26 Prakash I13014613 30/M 3 x x x x 39 days * grade 2
27 gajendran I12033174 27/M 11 x x x s 13 days * grade 2
28 Robetr Stalin I13017167 25/M 2 x x x x x 20days * grade 1
29 marichamy I12036102 25/M 11/15 x g2 s 17 days * grade 1
30 natchimuthu I13027015 51/M 2/15 x x x x 21day * grade 5
31 guhanesan I13024817 31/M 9/15 x x x 4days * grade 1
32 Krishnamoorthy I13021321 38/M 5 x x x x x s 15 days * grade 1
33 Udayakumar I13014444 35/M 8 x x x 10days * grade 2
34 ramesh I13020392 29/M 6 x x x s 25days * grade 3
35 palani I13028170 35/M 2 x x x x x x 9days * grade 5
36 sankar I13011320 43M 6 x x x X x x 4days * grade 3
37 chelladurai I12012886 51/M 9 x x 6days * grade 1
38 Chinasamy I13018593 57/M 10 x x x 7 days * grade 1
39 vijalakshmi I13011992 50/F 5 X x X x x s 90 days * grade 1
40 subramaniam I12013842 43/M 10 x x 8days * grade 1
41 venkatraj I12023221 28/M 5 x x X x x 64 days * grade 2
42 Rangasamy I1301852 42/M 8 x x x 9days * grade 1
43 gokul ranjith .b I13020056 34/M 8 x x x x x 7 * grade 1
44 ARUSAMY I13020024 30/M 12 X X X 3 DAYS * grade 1
45 arulraj I12016788 18/M 12 x x x 21 days * grade 1
46 palani .k O13066747 33/M 2 x x x x x 10 days * grade 1
54 subbulakshmi I13030349 59/F 12 x x x 13days * grade 2
55 ananda padma
naban I13031007 65/M 2 x x x X S
30DAY
S * grade 1
56 palanisamy I13032155 40/M 10 x x x 20 days * grade 1
57 venkitapathy I13032082 44/M 6 X x x X 2days * grade 5
58 palanisamy.k I13032372 70/M 5 x x x x 20 days * grade 5
59 veramuthu I13033779 43/M 7 x x x 10 days * grade 5
60 myilathal I13032499 50/F 11 x x x x 8days * grade 1
61 elankathir I13031608 33/M 12 x x x 9 days * grade 1
62 myilsamy O12009271 50/M 14 x x x x 14 days * grade 1
63 chandra mohan I14018792 44/M 2 x x x x x 7 days grade 5
64 muthusamy I13019791 41/M 11 x x x x x 9days * grade 1
65 hidyathula I13032223 48/M 15 x x 4 days * grade 1
66 ranganathan I14012797 41/M 12 x x x x 15 days * grade 1
67 Karthikeyan I13029281 30/M 12 X 10 days * grade 1
68 mohana
sundaram I14016306 36/M 7 x x g2 20days * grade 1
69 sathish O13073555 33/M 9 x x x 10days * grade 1
70 priyadharshini O14043640 27/F 6 x x x 1day * grade 4
71 ponraj I14007677 44/M 3 X x x 1day * grade 5
72 anjula I13029444 60/F 9 x x x x x x 30 days * grade 1
73 Duraisamy I14014269 51/M 3 X X 12days * grade 5
74 Ibrahim I14013994 45/M 8 x x x x 28 days * grade 3
75 gurusamy I14013559 40/M 6 x x x 14 days * grade 1
76 faizal I14010143 35/M 2 x x x x g2 10days * grade 5
77 saraswathi I14010485 36/F 12 x x x x 65days * grade 1
78 sundaraj I14009531 44/M 10 x x x 24 days * grade 5
79 shajahan I14012153 48/M 8 x x x x 29days * grade 1
80 senthil kumar I14009673 29/M 7 x x g2 x 15days * grade 1
81 arunkumar I14007591 28/M 7 x x x x x ?x x 21days * grade 1
82 muthusamy I14007652 55/M 8 x x x x 11days * grade 1
83 kanniammal I14011451 44/F 7 x x x 1 day * grade 5
84 senthil kumar I14009673 32/M 7 x x g2 15 days * grade 1
85 selvi I14008663 28/F 7 x x x 28 days * grade 1
